Dignity and the Eye of the Beholder

Mr. J was a 67-year-old man with an endstage gastrointestinal malignancy. Having decided he no longer wished to go on living, he had gone on a hunger strike, precipitating an admission to an inpatient tertiary palliative care unit. He reported that, aside from some minor discomforts, his symptom management was quite reasonable. Psychiatric consultation was initiated to determine if depression might be a factor influencing his wish to die. While he was not overtly suicidal, and in fact seemed ambivalent about his wish to die, he did state, “if I were in a European country where I could ‘press the button now,’ I would.” After careful evaluation, it was determined that rather than depression, the driving force behind his desire for death was a sense that life no longer held purpose, meaning, nor hope. While he spoke of a lingering wish to participate in various life activities, he bemoaned the fact that his body was simply too weak and too ill to allow him to do so. That being the case, he expressed the conviction that living had become redundant, his life had no worth, and there was little reason for him to carry on. How can we offer comfort to patients whose distress is primarily in the realm of the existential, or beyond the reach of an easily administered psychopharmaceutical or analgesic drug? While these matters are often deferred to the expertise of pastoral care professionals, there is a growing movement—particularly in reference to dying patients—for physicians to expand their caring with attentiveness to psychosocial, existential, or spiritual suffering. In the absence of a clinical depression or formal psychiatric disorder, the paucity of therapeutic options or formatted approaches can leave oncology practitioners at somewhat of a loss. There may be aspects of despair toward the end of life that may be inherent to the dying process itself. If such distress is not primarily an aberration of neurochemistry, but rather reflects a paucity of hope, meaning, and self worth, what can be done to safeguard or enhance those life-sustaining attributes? And if loss of meaning, hope, and self-worth are the essence of such despair, what implications does this have for palliative care providers?